Introduction: Nepal cannot afford renal replacement therapy for End Stage Renal Disease due to lack of resources. Early diagnosis of Chronic Kidney Disease and its risk factors may reduce the need of renal replacement therapy.Methods:A community-based screening on, 3218 people ≥20 years were assessed by door-to-door survey in Dharan, Nepal. Health status, lifestyle habit, physical examination and blood pressure were evaluated. Spot urine was examined for proteins and glucose by dipstick. Fasting blood glucose and serum creatinine were measured in a subset of 1000 people and the prevalence of Chronic Kidney Disease was evaluated.Results: Overweight, obesity, hypertension, diabetes and proteinuria were found in 20%, 5.0%, 38.6%, 7.5%, and 5.1% respectively. In the subset group, Chronic Kidney Disease was detected in 10.6%. Multivariate analysis indicated age (P <0.0001) and diabetes (P = 0.027) as statistically significant predictors for Chronic Kidney Disease. Total of 848 patients entered the management program of lifestyle modification and pharmacologic intervention. Glycemic and blood pressure control was achieved in 60% and 72%, respectively. Regression or stabilization of proteinuria was reported in 52% of patients. Conclusions: Burden of Chronic Kidney Disease and cardiovascular risk factors are high in Dharan. Reasonable control of blood sugar, hypertension and proteinuria was achieved in this program. Findings indicate that activation a large prevention and intervention program to tackle Chronic Kidney Disease and Cardiovascular Disease in Nepal is needed.Keywords: chronic kidney disease; community-screening; diabetes; hypertension; intervention; Nepal.

Background and aims: Acute myocardial infarction below 45 years of age constitutes a specific subset of population having different risk factors and clinical features as compared to older patients. Pattern of coronary artery involvement and clinical outcome also varies suggesting different underlying pathophysiology. Better understanding this specific problem will lead to further improvement in management. Methods: One hundred and fifteen consecutive patients diagnosed as acute myocardial infarction and were below 45 years over the period of one year were enrolled in the study. Clinical parameters, risk factors, angiographic patterns were analysed. Patients were assessed daily during hospital stay to study in-hospital outcome and complications. Results: Out of total patients studied, 64.3% were smokers, 27.8% were hypertensive, 15.65% were diabetic and 9.6% had history of dyslipidemia. There was history of recreational drug abuse in 4.3% of patients. Most patients present as ST elevation myocardial infarction (87%). Majority of patients were in Killip class I (69.5%) at presentation in emergency. Single vessel disease (58.3%) was the most common finding in coronary angiography and 7.6% patients have normal or non obstructive coronary lesions. Complications include arrhythmia (6%), cardiogenic shock (5.2%) and mortality (1.7%). Conclusions: In young acute myocardial infarction patients, smoking is the single most important modifiable risk factor. Other conventional risk factors are less strongly associated than older patients. Young patients tend to have less extensive coronary artery lesions. In few patients, presence of normal or non obstructive coronary lesions would suggest possibility of different mechanism of myocardial necrosis. Overall, these patients had favourable outcome and better prognosis. Nepalese Heart Journal | Volume 10 | No.1 | November 2013| Pages 12-16 DOI: http://dx.doi.org/10.3126/njh.v10i1.9740

Background: pleural effusion is the common fi ndings in patients presenting with cardiopulmonary symptoms but specifi c studies are lacking in Nepal. Objective: The main objective of this study is to fi nd out the various causes of pleural effusion, their mode of clinical presentation and laboratory analysis of blood and pleural fl uid to aid diagnosis of patients with pleural effusion. Materials and methods: Retrospective data from July 2009 to July 2007 from all the cases diagnosed with pleural effusion were taken. Altogether 100 cases diagnosed with pleural effusion by chest X-ray (Posterior-Anterior and Lateral view) and Ultrasonogram of the chest were studied. The following parameters were analysed: Patients demographic profi le, causes, location (Unilateral, Bilateral), Blood haemoglobin and count, sputum profi le, Monteux test, chest Xray and USG fi ndings and pleural fl uid analysis[Biochemical, Haematological, Microbiological(culture and stain) and cytological]. This study was analysed by using SPSS 16. Results: The mean age of the patient was 44.89 ± 21.59 and must patients with pleural effusion belong to age group 21-30. Most common cause of pleural effusion was found to be tubercular effusion followed by parapneumonic effusion. Right sided effusion was seen in most cases of tubercular parapneumonic and malignant effusion whereas bilateral effusion was seen in 87.5% of the patient (7 out of 8) having congestive heart failure and all cases of renal disease (4 out of 4). Shortness of breath (83%), cough (67%) and fever (66%) are the most common mode of clinical presentation. Conclusion: Our study concluded that the most common cause of unilateral pleural effusion is tuberculosis followed by parapneumonic effusion and most cases of those belong to younger age group (21 -30yrs) and most common cause of bilateral pleural effusion is congestive cardiac failure.

Introduction: A basic familiarity with orthopaedic disorders is important for all medical school graduates. The purpose of this study is to assess the adequacy of undergraduate orthopaedic knowledge among the first batch interns of our academy.Methods: The validated basic cognitive examination designed by Freedman and Bernstein, consisting of 25 short answer questions was administered to the first batch interns. Overall scores and responses to the individual questions were analyzed. The recommended passing score of 73.1 per cent as suggested by Freedman and Bernstein was considered. The overall unweighted and weighted scores were calculated. The questions were also separated into anatomy, general orthopedics and trauma groups. The Microsoft Office Excel 2007 was used for the statistical analysis.Results: Forty eight interns appeared the examination with the mean scores obtained was 58.79 per cent. Forty five interns (94 per cent) failed to demonstrate basic competency on the examination. The overall weighted score for all interns was 61 per cent. Forty two (88 per cent) of the 48 interns failed the examination even when the questions were weighted. The average scores in the general orthopedics, trauma and anatomy groups were 49, 76 and 54.6 per cents respectively.Conclusion: Majority (94 percent) of the first batch interns failed the validated basic musculoskeletal examination. Curriculum and teaching methods is inadequate or inappropriate and should be re-evaluated to address this problem.

Background and Aims There is little information on the incremental prognostic importance of frailty beyond conventional prognostic variables in heart failure (HF) populations from different country income levels. Methods A total of 3429 adults with HF (age 61 ± 14 years, 33% women) from 27 high-, middle- and low-income countries were prospectively studied. Baseline frailty was evaluated by the Fried index, incorporating handgrip strength, gait speed, physical activity, unintended weight loss, and self-reported exhaustion. Mean left ventricular ejection fraction was 39 ± 14% and 26% had New York Heart Association Class III/IV symptoms. Participants were followed for a median (25th to 75th percentile) of 3.1 (2.0–4.3) years. Cox proportional hazard models for death and HF hospitalization adjusted for country income level; age; sex; education; HF aetiology; left ventricular ejection fraction; diabetes; tobacco and alcohol use; New York Heart Association functional class; HF medication use; blood pressure; and haemoglobin, sodium, and creatinine concentrations were performed. The incremental discriminatory value of frailty over and above the MAGGIC risk score was evaluated by the area under the receiver-operating characteristic curve. Results At baseline, 18% of participants were robust, 61% pre-frail, and 21% frail. During follow-up, 565 (16%) participants died and 471 (14%) were hospitalized for HF. Respective adjusted hazard ratios (95% confidence interval) for death among the pre-frail and frail were 1.59 (1.12–2.26) and 2.92 (1.99–4.27). Respective adjusted hazard ratios (95% confidence interval) for HF hospitalization were 1.32 (0.93–1.87) and 1.97 (1.33–2.91). Findings were consistent among different country income levels and by most subgroups. Adding frailty to the MAGGIC risk score improved the discrimination of future death and HF hospitalization. Conclusions Frailty confers substantial incremental prognostic information to prognostic variables for predicting death and HF hospitalization. The relationship between frailty and these outcomes is consistent across countries at all income levels.

Background and Aims: Incidence of ST-elevation myocardial infarction (STEMI) is increasing in Nepal. We aim to describe the presentation, management, complications, and outcomes of patients admitted with a diagnosis of STEMI in Shahid Gangalal National Heart Centre (SGNHC), Nepal. Methods: Shahid Gangalal National Heart Centre-ST-elevation registry (SGNHC-STEMI) registry was a cross sectional, observational, registry. All the patients who were admitted with the diagnosis of STEMI from January 2018 to December 2018 were included. Results: In this registry, 1460 patients out of 1486 patients who attended emergency were included. The mean age of patients was 60.8±13.4 years (range: 20 years to 98 years) with 70.3% male patients. Most of the patients (83.2%) were referred from other hospitals and 16.8% of patients directly attended the SGNHC emergency. During the presentation, smoking (54%) was the most common risk factor, followed by hypertension (36.6%), diabetes mellitus (25.3%), and dyslipidemia (7.8%). After admission, new cases of dyslipidemia, HTN, Impaired Fasting Glucose (IFG), and Type 2 DM were diagnosed in 682 (51.3%), 182 (20.1%), 148 (10.3%) and 95 (8.9%) respectively. At the time of presentation, 73.3% were in Killip class I and 26.3% were above Killip class II with 5.1% in cardiogenic shock. Thirty-one percent of the cases received reperfusion therapy (Primary percutaneous intervention in 25.2% and fibrinolysis in 5.8%). Inferior wall MI was the most common type of STEMI. Among the patients who underwent invasive therapy, the multi-vessel disease was noted in 46.2% cases and left main coronary artery involvement in 0.7% cases. In-hospital mortality was 6.2% with cardiogenic shock being the most common cause. Aspirin (97.8%), clopidogrel (96.2%), statin (96.4%), ACEI/ARB (76.8%) and beta-blocker (76.8%) were prescribed during discharge. Conclusion: The SGNHC-STEMI registry provides valuable information on the overall aspect of STEMI in Nepal. In general, the SGNHC-STEMI registry findings are consistent with other international data.

Background and Aims: : Coronary angiogram detects anatomical lesion, however, has limited ability to assess physiological significance. Fractional flow reserve is used to determine functional significance of stenosis and is measured by the ratio of mean distal coronary pressure to mean aortic pressure during maximum hyperemia. Recently, fractional flow reserve was started in Nepal. This study intends to explore the extent of determination of hemodynamic significance of intermediate coronary stenosis by fractional flow reserve, thereby guiding revascularization. Methods: Consecutive patients with intermediate lesion undergoing fractional flow reserve from July 2014 to March 2015 were included, if fractional flow reserve ≤0.80 then considered to be significant and need for revascularization determined. The study subjects were divided into two groups, one having physiologically significant stenosis and another with physiologically non significant lesion and followed up to three months. Results: Total forty four patients had fractional flow reserve done in fifty eight intermediate coronary artery lesions. The age ranged from 33 to 78 with the mean age of 58.25±10.08 years. Majority of them (75%) were male. Left anterior descending artery was commonest in 37(63.8%), followed by left circumflex 13(22.4%), then right coronary artery in 8(13.8%) target lesions. None of the patient had death, myocardial infarction or repeat revascularization during follow up. Out of 58 intermediate lesions assessed, 17(29.31%) had significant fractional flow reserve value, whereas 41(70.69%) had physiologically non significant lesion. Conclusion: Around one third (29.31%) of intermediate coronary artery stenosis are functionally significant by fractional flow reserve in the context of Nepal, thus it could be useful guide for optimal revascularization.

Background and Aims: Determining the severity of mitral stenosis (MS) is important for both prognostic and therapeutic reasons. Measurement of Mitral valve area (MVA) by planimetry is gold standard and accurate but is highly operator dependent. Pressure Half Time (PHT) is affected by hemodynamic significance. In this Study we evaluated severity of mitral stenosis by mitral leaflet separation index (MLS index, MLSI). This new index could be useful surrogate measure of the MVA. Methods: This is a hospital based, cross-sectional observational study carried out in Shahid Gangalal National Heart Centre (SGNHC), Kathmandu, Nepal. Study included 82 patients with Rheumatic MS who had undergone echocardiographic examination from July 2018 to December 2018. The maximal separation of the mitral valve leaflet tips was measured from inner edge to inner edge in end diastole in the parasternal long axis and apical 4-chamber views. These two parameters were averaged to yield the MLSI. The index was compared with mitral valve area determined by planimetry method and PHT. Results: Of the 82 study subjects, majority were females 72 (85.4%). The mean age of study patients was 37.33±11.56 years. 30.5% had mild MS by planimetry, 31.7% had moderate MS and 37.8% had severe MS. There was a very strong correlation between MLS index and MVA by planimetry ( r = 0.89, p<0.001) and MVA by PHT (r=0.95, p<0.001). MLS index less than 0.73 cm can predict severe MS with 93.2% sensitivity and 89.3% specificity. On the other hand MLS index more than 1.035cm can predict mild MS with 70% sensitivity and 89.3% specificity. Strong correlation exists between MLS index and MV severity in presence atrial fibrillation (AF) (r=0.879) for planimetry and (r=0.835) for PHT and in presence of coexisting mitral regurgitation (MR) (r=0.89) for planimetry and (r=0.86) for PHT. Conclusion: MLSI has a strong correlation with MVA by planimetry and PHT. So, it can be used as a reliable method to assess severity of mitral stenosis and is a simple and easily obtainable. It has good correlation even in presence of AF and MR.